I HAVE on this date personally examined [Name of employee], knowing him to be (an applicant for a licence to drive) (to be employed in driving) an electric tram; he has informed me of the purpose of all medical attention he has received during the year last past; and I have questioned him regarding any fits or other attacks of sudden unconsciousness to which he may be or may at any time have been subject. The results of my examination are as follows: 1 Eyesight—Right eye: Left eye [Each eye should be either (a) of six-ninths standard without glasses or better; or (b) of six-sixths standard with glasses.] Note—Where the person has the use of only one eye that eye should be of six-sixths standard without glasses and the certificate by the medical practitioner is subject to confirmation by the promoter in respect of the other requirements of regulation 4 of the regulations. 2 Colour vision: (Satisfactory) (unsatisfactory). 3 Hearing: (Satisfactory) (unsatisfactory). [The employee should be able to recognise words uttered in an ordinary conversational voice at 10 ft.] 4 The respiration (is) (is not) natural and the respiratory sounds and the resonance of the chest are (normal) (abnormal). 5 The pulsations of the heart (are) (are not) natural in rhythm and force, and its sounds (are) (are not) those of health. [NOTE—An employee is not necessarily unfit by reason only of an adverse finding under item 4 or 5.] 6 The blood pressure is—Systolic: Diastolic: 7 The employee (is) (is not) free from any physical or other defect and from any temperamental or psychological characteristic that would interfere with his efficiency as a driver of an electric tram. I hereby certify that in my opinion, having all proper regard to the safety of passengers and of the public generally, the employee is (is not) mentally and physically a fit and proper person to drive an electric tram. Date: Registered Medical Practitioner.